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Tesfaye Ejigu

A city,where the government has built no new hospital for the last 22 years, is struggling with its few outdated and under supplied state run hospitals 

Around end of October 2013, the online version of Addis Standard published an opinion piece discussing an eight hour power outage and a dysfunctional power generator at Tikur Anbessa (Black Lion) Hospital, a state run hospital in Addis Ababa. Written by Fitsum Tilahun (MD), it revealed what might have happened during that fateful moment at the hospital. “You can expect a lot of bad things to happen when you go to any hospital in Ethiopia…but what you don’t expect is to see your new born baby die from hypothermia or see your patient who is in life support machine die because of power outage,” wrote Fitsum. Many of our readers said it was “unacceptable,” “outrageous,” and “irresponsible.” They were right.

Unfortunately, Black Lion Hospital is no stranger to similar awful turn of events. In 2005 a power outage caused the death of seven patients in the Intensive Care Unit (ICU). It is too ghastly to be true about a hospital “where the most critical of patients are admitted”, Fitsum said. Not only that, Black Lion Hospital is one of the oldest hospitals in the country and is located in a city many refer to as the “Capital of Africa.” In the year 2010/11, the hospital admitted more than 250, 000 patients; and at any given moment it admits from 800 -1000 patients.

Disturbingly however, the mess at Black Lion’s is not a single case: in September 2013, an article published in a local Amharic bi-weekly raised an alarming topic in which the writer discussed absence of mechanical ventilation in major hospitals run by the government and its dreadful consequences; two months later, in mid November, members of the senior management at St. Paul Hospital, another state run hospital in Addis Ababa, complained that the hospital was getting its water supply only once every week, which forced the hospital  to use germ-infested water from an old tanker.They also said the hospital has no laboratory facilities. In the year 2010/11 St. Paul hospital admitted more than 110, 000 patients; and at any given moment it admits from 600 – 800 patients.

Visits to most of the 12 state run hospitals in Addis Ababa bring stories bleaker than one is prepared to take. A woman who takes care of her mother, who is an outpatient follow-up for a tumor at Zewditu Memorial Hospital since 2010, told Addis Standard that health care service at the hospital has deteriorated lately.  “Patient cards get mislaid. Every time we go for a follow up, we take card afresh as if on a first visit. All the previously written medical history also gets lost. How can the tumor be followed into progress when we have no records of the case at the onset?” the woman asks desperately.

 What’s it with state run hospitals?

Currently, Addis Ababa has 12 state run and more than 40 private hospitals. Many of the later were built in the past 21 years. In sharp contrast however, all of the state run hospitals were built more than 30 years ago. For a city of an estimated four – five million, state run hospitals are the best medical care alternative centers used mostly by the middle-to-low income inhabitants of the city. However, Black Lion hospital is the largest referral hospital in the country where even the sick wealthy are referred to before flying out of the country.

Not an encouraging view /Photo Addis Standard
Not an encouraging view /Photo Addis Standard

Out of the 12 hospitals, the Federal Ministry of Health (FMoH) administers four, two are under the Army and Police, five are under the city government of the Addis Ababa health bureau and one (Black Lion Hospital) is under the Addis Ababa University, which was given to it in 1998 from the FMoH to be used as teaching hospital. In the year 2010/11 all state run hospitals in Addis Ababa have admitted more than 1.2 million patients.

Low doctor-to-population ratio (estimated to be 1:20, 000,and 1:3, 000 nurse-to-population ratio nationwide) coupled with lack of medical assistants such as anesthetists and midwives and lack of medical equipment including essential pharmaceuticals are common tales not just in Addis Ababa, but throughout the country. In Zewditu Memorial Hospital, for example, simple medical equipment such as glucometer strip, disposable gloves, mask, and alcohol are always in short supply even in the emergency section. A source at the hospital said X-ray department without X-ray films or a laboratory without a reagent or a CD4 count is not uncommon.

According to a January 2011 survey by Cardno Emerging Markets and Enabling Environments Ltd., Ethiopia had only eight local manufacturers of various pharmaceutical products including medical supplies, but none of them “meet the World Health Organization’s basic Good Manufacturing Practice (GMP) standards”; and the local production represents “less than 10%” of the total market for pharmaceutical products.

Semeneh Daketo, team leader at Zewditu hospital Planning, Evaluation and Monitoring section, has something else to put the blames into: the Pharmaceutical and Medical Supply Import and Wholesale Share Company (PHARMID). “For complaints of material shortage, PHARMID takes the blame” Semeneh told this magazine. “PHARMID, as the only supplier of medical equipment is a monopoly.” Although the Pharmaceutical Administration and Supply Service (PASS) of the FMoH is equally responsible for the import and distribution of pharmaceutical supplies, PHARMID is more practical in participating both in local and international tenders. However, PHARMID’s doing of business is notorious for its ineffective bureaucracy; it neither enlists out-of-stock items, nor it provides supplies on time. Private suppliers have to abide by authorized items only; and hospitals are not allowed to buy materials on their own, even if they have the financial capacity.

Given that most of the hospitals were built decades ago, lack of medical infrastructure and out-of-date facilities are all-too-common, too. Some departments of these hospitals have medical equipments that are old and falling to pieces that they are literary unusable; lack of biomedical professionals means most of these rundowns can’t be repaired.

Currently, expansion constructions are taking place at Zewditu Memorial, Ras Desta Damtew, Menellik II and Yekatit 12 hospitals. But it doesn’t explain the rationale behind the current government’s reluctance to open new hospitals in the capital in nearly 22 years. According to a 2012/13 annual performance report by the FMoH, a total of four new hospitals were completed in Oromia, Somali and Southern Nation Nationalities and Peoples’ regions, whereas six regions are constructing 175 hospitals. “Six hospitals in four regions have been upgraded and the total number of hospitals available has reached 127”, the report says. But the figure for Addis Ababa both in newly completed, ongoing construction and upgrade shows zero. Nor do expansion constructions guarantee flawless supplies of drugs and availability of up-to-date medical equipment.

Slow (and perhaps ineffective) reform

Although not all hospitals in Addis Ababa are administrated by the FMoH, under the impeccable leadership of former minister, Dr. Tedros Adnahom, (now the Minister of Foreign Affairs) the FMoH had embarked on a wide range reform particularly since 2006, the year when Dr. Tedros launched the Ethiopian Hospital Management Initiative (EHMI). Some of the programs under EHMI focus on improving the management of hospitals and health care centers by equipping them with trained professionals. Traditionally, almost all of the state owned hospitals throughout the country are run by physician medical directors who not only have to run hospitals but also spend a significant amount of their time caring for patients.

In 2008, a collaboration between the FMoH, Yale University, Jimma University in Ethiopia and the then William Jefferson Clinton Foundation AIDS Initiative (CHAI) to train hospital CEOs saw a remarkable result when, in 2010 (one year later than it was planned), Jimma University graduated 25 Hospital CEOs (two women and 23 men) with Master of Healthcare and Hospital Administration (MHA). However, out of the 25, Addis Standard could trace only one of the two women, Liya Tadesse (MD), as being assigned to work at St.Paul Hospital.  Thirty graduates of the second round (one woman and 29 men), were all assigned as hospital CEOs in different regional cities.

As a further effort by the government to reform the sector, EHMI was followed by the infamous Business Process Reengineering (BPR), a reform largely unsuccessful in many civil services offices despite it brought nearly every government office to a terrible standstill during its implementation.

Sister Sannya Awel, head of the Planning, Evaluation and Monitoring section at the Addis Ababa health bureau, which has a declared goal of improving “the health status of the residents of Addis Ababa by providing quality and comprehensive health service,” and is currently supervising the administration of four of the 12 hospitals, was happy to talk about the positive changes registered in the health sector over the last few years. As evidence she mentioned hospitals under expansion. Ras Desta Damtew hospital, for example, has constructed a new Mother and Child Health (MCH) center; and a fifth hospital, with four different medical disciplines, went operational in Akaki-Kaliti sub-city very recently. “All this is to make health service accessible to the ordinary people,” Sister Sannya told this magazine.

According to a 2011 paper by Liya Tadesse, all hospitals were implementing “the revised comprehensive Hospital Reform Implementation Guideline with 13 chapters on key areas.” But Liya wrote, “the big challenge is that hospitals are mainly trying to implement the new reforms with the currently existing human power and budget to achieve all these standards.”

Although Liya says that “we have a long way to go but [I] believe we are on the right track,” for Fitsum reforming a health care for a city where millions live can be a day late, a dollar short. “Patients on critical condition put on mechanical ventilation can’t survive more than few minutes with their machine off let alone for seven hours,” he wrote, “Frozen lab samples, [and] pathology specimens stored on a freezer will be discarded. You can’t imagine what the patients went through to give that sample, and in some instance it is a sample that can’t be done again. Even routine care can’t be done with lights off for the 800 plus hospitalized patients and basic diagnostic services will not be available.”

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